Sunday November 1, 2009
Not your usual mental asylum
Stories by CHAN LI JIN
Find out how the country’s largest mental institution is leading the charge in raising the quality of mental health care in Malaysia.
QUESTION: If a man walks backwards from Perlis to Johor Baru and another does the same from Johor Baru to Perlis, where would they meet?
Answer: In Tanjung Rambutan. Because only orang gila (lunatics) would walk backwards from one end of the peninsula to another.
If you are Malaysian, you would know right away that the punchline refers to the home of the country’s first and biggest mental institution. Such is the fame – or should that be infamy? – of Tanjung Rambutan, Perak.
It looks like any other small town in Peninsular Malaysia. There’s the single main road lined with shophouses. There’s the police station and school that take pride of place in the town’s heart. There’s the small railway station at which old-timers congregate every day for their morning kopi.
And that’s where the similarity ends. Because behind the railway station sits Hospital Bahagia, the new name of Tanjung Rambutan’s hospital since the 1970s.
Even before the hospital gained a reputation as the main centre of reference for legal cases related to mental illness, it was already so well-known that it was mentioned in Tan Sri P. Ramlee’s 1961 hit movie, Seniman Bujang Lapok.
Someone’s lovely little house and garden? No, this is one of the wards on the grounds of Hospital Bahagia at Tanjung Rambutan. The garden is maintained by some of the ward’s more green-fingered inmates. – Photo by CHAN LI JIN A walk in the park
Literally and symbolically hidden from public view behind railway lines and trees, Hospital Bahagia sprawls over more than 200ha or greenery. Located approximately 25km from Ipoh, the hospital is easily accessible today via well-maintained roads, unlike the past when the main access was via the train service.
People entering Hospital Bahagia for the first time are often surprised. Instead of a gloomy, formidable-looking institution that movies would have you expect, what you see is beautifully landscaped gardens around small buildings set amidst a wide open space.
There is a modern two-storey building that serves as an administrative centre and day-care and outpatient clinic. There is also a library, a hostel for the Allied Sciences College, a launderette, and farming land and fish ponds. Wards housed in buildings painted in cheerful shades of orange, green and yellow dot the landscape as far as the eye can see. In short, it is like a self-contained village – and a pretty one, too.
On weekends and special occasions, the fish ponds come alive when both patients and the public come together for fishing competitions. Dragon fruit plants, heavy with fruit, await harvesting by rehabilitated patients who are staying at the hospital while waiting to rejoin society.
The serenity of the surroundings accurately reflects its name, Hospital Bahagia, which means “happy hospital” in Malay. But it’s no bucolic backwater and plays an important role in mental health care and services for the country.
“We get a lot of visitors these days,” says Datuk Dr Suarn Singh, consultant psychiatrist and the hospital’s director. “They’re both medical and non-medical groups and individuals who want to learn more about mental health care. With rising levels of mental illnesses, people are now increasingly aware of the need for preventive health care especially in mental health.
“We talk to them about stress management, problem-solving, communication skills and more.”
Visitors are more than welcome, as the hospital wants to increase awareness of mental illness and remove the stigma. People need to know that mental illnesses are like any other chronic disease, such as diabetes, hypertension or heart disease, stresses Dr Suarn, who is also the technical advisor for the Health Ministry’s psychiatry services.
“The problem is that mental disorders are not easily identified. People usually describe them as disturbed and abnormal behaviour, but that, too, can be open to interpretation,” says Dr Suarn.
In the past, people who were thought to be mentally ill were brought to Hospital Bahagia for assessment, only for the hospital’s psychiatrists to discover that the patients had organic conditions such as a brain tumour or hypothyroidism.
As these conditions mimic psychiatric disorders with symptoms such as depressive behaviour, hallucinations and suicidal tendencies, healthcare professionals need to carefully study the patient’s medical history to correctly identify the condition. Tests need to be carried out to rule out all organic conditions before a diagnosis of mental illness can be confirmed, adds Dr Suarn.
Modern apartment-style accommodation replaced many of the old wooden ward cottages that had been falling apart from termites. -Photo by CHAN LI JIN New millennium mental healthcare
In the old days, mental asylums were built for one main purpose: to keep mentally ill patients away from the general public. Over the last century, however, the availability of better drugs and therapies for mentally ill patients has much improved psychiatric treatment.
“Hospital Bahagia now practises a more wholesome approach by engaging patients’ families to play an active role in the recovery process. Our past efforts with home care services (see How it all started below), have shown promising results, with a significant reduction in re-admission and relapse cases,” says Dr Suarn.
This approach is partly dictated by the limited number of psychiatry specialists in the country. At the moment, we only have approximately 200 psychiatrists, which is a ratio of 1:140,000 people. Dr Suarn points out that this is a far cry from World Health Organisation (WHO) recommendations of 1:50,000 people.
To mitigate the lack of psychiatrists, mental health services have been decentralised throughout the country. Apart from the four main mental institutions – Hospital Bahagia, Hospital Bukit Padang (Sabah), Hospital Permai (Johor) and Hospital Sentosa (Sarawak) – the Health Ministry now also has psychiatry services in 32 hospitals nationwide.
Hospital Bahagia is also a centre of training for psychiatrists that is accredited by the Conjoint Board, which comprises the Health Ministry, Universiti Kebangsaan Malaysia, Universiti Malaya, Universiti Putra Malaysia and Universiti Sains Malaysia.
Meanwhile, sub-specialist training in forensic psychiatry (a combination of the law and psychiatric practice that deals with issues like criminal responsibility) as well as community and rehabilitation psychiatry is conducted at Hospital Bahagia. Other sub-specialist training is offered at three other hospitals.
“In a nutshell, keeping people in an institution is costly. As such, the new direction in mental health worldwide is towards ‘community care’, outpatient treatment and minimising admission rates and length of stay,” explains Dr Suarn.
Seeing how peaceful the surroundings are, I can’t resist asking, “So how does one get admitted?”
It’s as good as staying in a holiday resort, free of charge, I venture.
But, apparently, it’s not easy. Basically, patients are warded based on two main criteria: when they are harming themselves (aggressive, with tendencies towards self-injury or suicide) or when they are harmful to others. They may voluntarily ask for admission or they can be brought in by family members or the police under civil or criminal law.
All patients at Hospital Bahagia would already have medical records of mental illness and are usually referred there by doctors from state and district hospitals.
“The patients are then segregated according to the severity of their condition. If their condition is acute, they will be kept in close observation wards. When their condition improves, they will be shifted to open wards, before being ‘upgraded’ to apartments where they can stay until they are well enough to return to society,” explains Dr Suarn.
The problem is, many recovered patients find it hard to fit back into society because they have been abandoned by family and friends. Currently, there are about 800 patients aged 60 and above, many of whom have been staying in Hospital Bahagia’s geriatric wards for the last 15 years – and some have been there since the nation’s independence in 1957!
Again, we are back to the problem of stigma, Dr Suarn laments, explaining that this is why family involvement is so crucial.
Each flat is comfortably furbished with basic necessities, which inmates are responsible for caring for. -Photo by CHAN LI JIN Treatment for the patient is thus broadened from medications and confinement to a more holistic approach using biological factors (medications) combined with psychotherapy (problem-solving skills, counselling) and social manipulation (communication skills with family).
Mental illness does not only affect the individual but the entire family, and the family needs support and care just as much as a patient.
That’s where hospital-based psychiatry services come into play. Seeking treatment at a general hospital and community health clinics is more appealing to both patient and family members, as others will not suspect that they’re seeking treatment for a mental illness. This effectively removes the problem of stigma.
So do patients request to be kept longer than necessary just to enjoy the calm and peaceful environment?
Not really, says Dr Suarn with a smile, because there is no place like home: “No one wants to be isolated. Getting back to a normal life, where one has a job and loving relationships with family and friends, is every patient’s goal.”
The way forward
While schizophrenia is a major psychiatric disorder (it alters a person’s perception, thoughts, affect and behaviour) and is probably one of the more well-known mental diseases – we actually have a National Mental Health Registry for Schizophrenia – Dr Suarn thinks depression and anxiety are two of the bigger problems in this country that may have been overlooked thus far.
These problems are not easy to diagnose, and symptoms are often dismissed by family, friends, and even doctors.
Dr Suarn relates the case of a nurse in her 40s who kept complaining of unexplained pains. With a happy family of three children and a caring husband as well as a stable career there seemed to be no reason for her to be anything but content. But further investigations showed that she had been severely depressed for more than two months and was almost suicidal by the time her condition was correctly diagnosed.
Psychiatrists are also seeing an increasing number of youngsters with mental illness as a result of amphetamine abuse. Conversely, there are also people who turn to drugs to deal with the psychotic symptoms they experience.
“These people may already have early signs of mental illnesses such as paranoia, hearing voices or seeing ‘things’. Having a strong network of family members and friends who recognise these symptoms as mental disorders instead of supernatural disturbances or just work stress would help tremendously,” he says – hence Hospital Bahagia’s efforts to educate the public.
Part of those efforts includes a partnership between the hospital and the Kinta Alliance for the Mentally Ill (Kami), a Perak-based support group for families of mentally ill patients. Kami provides family support and conducts activities such as earth camps, drum and craft circles, and laughter yoga as holistic therapy for patients and family members.
With the strong support of Hospital Bahagia expertise as well as the Circle of Care programme under the auspices of the Malaysian Psychiatric Association, Kami is currently helping to set up similar support groups throughout the country.
“Not many people understand how difficult it can be to care for a mentally-ill patient. Because mental illness affects the part of your brain that handles memory and instincts, patients can forget basic life skills such as reading and counting or even getting dressed, cooking, and holding a spoon.
“Healthcare providers need to teach these skills to patients and they have to teach caregivers how to continue with the process when the patient is back home,” says Dr Suarn.
Giving hope
Another successful approach that has been used by the Hospital Bahagia team is that of Supported Employment. An example is the Circle of Care “Car Wash and Polish Project” that was initiated in 2006 to provide job opportunities for recovered patients.
The project, in partnership with the Malaysian Psychiatric Association, turned out to be a roaring success, with people from surrounding districts supporting the patients by bringing in their vehicles for cleaning.
Similar successes have come from the coconut and dragon fruit farms, which are bringing in income for the hospital while at the same time providing work opportunities for patients.
The positive impact of such programmes has become a catalyst for more job placements in mainstream society for recovered patients.
Work gives patients a sense of worth and respect, says Dr Suarn. Patients who are gainfully employed are also more compliant and are active participants in their treatment process because they want to remain well.
But Dr Suarn warns that success doesn’t come easily, as it requires a lot of intensive follow-up sessions with the family before and after the patient is discharged from the hospital. Apart from ensuring the patient is compliant with medications, they must also cooperate in the initial stages of employment until the patient is confident enough to be independent.
What every patient needs is hope. The ability to work and earn their own money, along with the care and love of their family members, provides just that.
So will there be a day when Hospital Bahagia ceases to become relevant, in view of the decentralisation of mental healthcare services to state hospitals nationwide?
Dr Suarn does not worry about that.
“We are already seeing fewer patients at Hospital Bahagia due to the decentralisation process. I hope to see the day when Hospital Bahagia becomes a fully focused centre of reference for forensic cases as well as challenging psychiatric cases.
“We are slowly getting there.”
Related Stories:
How it all started
Man on a mission
Getting away with murder?
Mental health milestones
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